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ONSITE WA'.XWATER TREATMENT SYS PERMIT <br /> SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304E WESERA 3"°Fl,-STOCKTON CA 95202 - (209)468-3, <br /> NON-REFUNDABLE PERMIT �r CAL 209 953-7697 FOR INSPECTIONS EXPIRES YEAR FROM DATE ISSUE. <br /> JOB ADDRESS L7>:/ C <br /> IT <br /> Y <br /> /ZIP <br /> CROSSSTREET N'� // APN �� -Z-/-d X� PARCEL SIZE <br /> [ <br /> OWNER NAME 1�1 [!'/fi2j L/.�+//+BT � PHONE /�` <br /> �+ 7�—c?M/ y <br /> OWNERADDRESS �•ydl11�Q� CITY/STATE/ZIP <br /> CONTRACTOR �/ PHONE <br /> CONTRACTOR ADDRESS 0, CITY/STATE/ZIP <br /> LICENSE ❑CA2 ❑C-36 OTHER I NUMBER JIMA X1 EXPIRATION DATE <br /> WATER TABLE DEPTH: ft GEOGRAPHICAL INFORMATION: Coordinates X Y <br /> ❑ PERC TEST # BUILDING PERMIT# LAND USE APPLICATION# <br /> TYPE OF WORK: ❑ NEW INSTALLATION ❑ REPAIR/ADDITION ❑ ENGINEERD IGNED/ALTERNATIVE <br /> ❑ REPLACEMENT ❑ DESTRUCTION <br /> INSTALLATION WILL SERVE: ❑ RESIDENCE ❑ COMMERCIAL '❑ OTHER <br /> NUMBER OF LIVING UNITS: NUMBER OF BEDROOMS: NUMBER OF EMPLOYEES: <br /> ❑ SEPTIC TANK TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ GREASE TRAP TYPE/MFG CAPACITY gal #OF COMPARTMENTS <br /> ❑ PKC TX PLANT DISTANCE TO NEAREST: WELL ft FOUNDATION ft PROPERTY LINE ft 1j <br /> 13LIFT STATION SIZE TYPE OF PUMP ❑ SAND OIL SEPARATOR(ENCLOSED SYSTEM) C� <br /> ❑ LEACH LINES ❑ LEACHING CHAMBERS #OF LINES LENGTH OF LINES ft <br /> DISTANCE TO NEAREST WELL R FOUNDATION ft PROPERTY LINE ft <br /> ❑ FILTER BED WIDTH ft LENGTH ft DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft <br /> ❑ MOUNDED WIDTH ft LENGTH ft DEPTH ft TI <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> ❑ SUMPS WIDTH ft LENGTH ft DEPTH ft 'T <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LINE ft (L <br /> ❑ DISPOSAL PONDS WIDTH ft LENGTH ft DEPlH R fpm <br /> DISTANCE TO NEAREST WELL R FOUNDATION It PROPER ME ft (- <br /> ❑ SEEPAGE PITS NUMBER WIDTH R DEPTH ft <br /> DISTANCE TO NEAREST WELL ft FOUNDATION ft PROPERTY LME ft <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED S APPLICATION AND THE WORK WILL BE DONE IN ACCORDANCE WITH SAN JOAQUIN COUNTY <br /> ORDANCES, E LAWS AND RULES AND REGULATIONS OF SAN JOAQUIN COUNTY. <br /> UM H AN -NOTICE REQUIRED FOR INSPE TIONS-PLEASE'CAL (209)953-7697 p, <br /> SIGNED TITLE �1� DATE <br /> r 1 <br /> 77 <br /> �� �V/11 ' _ Ia Y• <br /> —f ft <br /> — <br /> ,.. q { _ <br /> EPARTMENTIISEgNLV, <br /> Application Accepte Date 157Zj?16p Area Employee ID# <br /> Final inspection Date ❑ SPECIAL PERMIT-Approved by <br /> Character of Soil ty6.Pth of 3 Pt: Pitl ump Soil CharIacter. <br /> COMMENTS �'cw t -n4►t 14 �Po•{ x��� LL QrIC Lc <br /> /G C/ 2 77 Ivry �'Xe�i ✓4.ss-4�7 xen/z—a� -4f:, r77 <br /> � .Bt/ •ec+� <br /> PE SC Received ChecW/ Amount Permit/Code INFO B Remitted D0� Service Request# OV&Invoice# Permit ID# <br /> SITE WAST WAT RPERMIT <br /> 12/22!!081 <br />